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PRIMARY CUSTOMER  
Last Name:   Zip:   Home Phone:  
 
First Name:   County:   Cell Phone:  
 
MI:   Date of Birth:   Facsimile:  
 
Address:   SSN#:   E-mail:  
 
City:   State:   Marital Status:  
 
 
Co-Signers / Guarantors / Co-Purchaser
Customer Name City State Type
       
 
 
   
Operating Information
Number of Trucks and Trailers Owned / Leased:       TRUCKS:   TRAILERS:  
Experience Since:   As OWNER:   As DRIVER:    
  MO / YR   MO / YR    
Commerical Drivers License Number:   CDL State:  
 
Previously Filed for Bankruptcy:     Prev. Bankruptcy Date:   Bankruptcy Type:  
 
Previously Repossessions:     Prev. Repossession Date:  
 
COMMENTS:  
 
 
 
Contracts to Haul
Business Name Material Hauled Start Date Contact Name Phone Number Contract/Lease Type   Mo. Income Miles per Yr
               
 
               
 
 
Hired Driver Information (Complete this section if truck is to be operated by a hired driver)
Last Name:   Phone:   Start Date:  
 
First Name:   MI:   Commerical Drivers License #:  
 
Address:   CDL State:  
 
City:   State:   Zip:  
 
 
Financing Information
Business Name Contact Name Phone Number City State
         
 
 
Other Loans and Installment Obligations
Business Name Phone Number Account Number Balance Unpaid Monthly Payment
         
         
 
 
Other Information
Spouse Name:   Phone:   Position:  
 
Employer:   Contact:   Start Date:  
 
City:   St: Zip:   Monthly Income:  
 
 
Additional Comments:
 
 
I (WE) ACKNOWLEDGE RECEIPT OF NOTICE IN COMPLIANCE WITH THE FEDERAL EQUAL CREDIT OPPORTUNITY ACT IF APPLICABLE THE FOREGOING APPLICATION HAS BEEN CAREFULLY READ (BOTH PRINTED AND WRITTEN MATTER) AND IS IN ALL RESPECTS COMPLETE, ACCURATE, AND TRUTHFUL. THIS APPLICATION IS GIVEN FOR THE USE OF UTILITY TRI-STATE, INC., AND IT'S AGENTS OR ASSIGNEES, AND THE UNDERSIGNED HEREBY AUTHORIZES THE ABOVE NAMED BANK(S), TRADE AND/OR OTHER CREDIT REFERENCE(S) TO RELEASE SUCH INFORMATION AS IS NECESSARY TO ESTABLISH CREDIT WITH UTILITY, IT'S AGENTS, OR ASSIGNEES.
I (WE) FURTHER REPRESENT THAT SAID EQUIPMENT SHALL BE USED FOR A COMMERCIAL PURPOSE AND NOT BE USED FOR ANY UNLAWFUL PURPOSE.
Signature of Applicant:   Date:  
                         
                         

Last Updated on 04/18/06

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